Complementary and integrative interventions for PTSD.

ABSTRACTTo treat the impact of trauma, most current evidence supports the use of trauma-focused psychotherapy as the first line approach. However, millions of individuals exposed to trauma worldwide seek Complementary and Integrative Health (CIH) therapies in hopes of achieving wellness above and beyond reducing symptoms. But what is the evidence for CIH interventions? What are potential pitfalls? Given the growing popularity of and strong interest in CIH, EJPT is featuring research on these approaches in this special issue. The papers range from common interventions such as mindfulness to the use of service dogs and scuba diving to alleviate trauma related symptoms. A featured editorial highlights the importance of defining when, where, and how placebo responses work. Nonspecific elements of treatment such as positive expectations, therapeutic rituals, healing symbols, and social interactions are identified as factors influencing treatment response and scientists looking to add to the CIH evidence base are encouraged to consider the impact and methodological challenges these elements present. CIH interventions more specifically recognize and harness some of these factors in addition to intervention-specific factors such as attention or emotion regulation along with focus on overall wellbeing. The body of work in this special issue supports the emerging evidence for meditative and relaxation-based interventions and illustrates a creative but nascent state of the field. Cross-intervention mechanisms that may play a role in achieving wellness, such as arousal reduction, emotion regulation, posttraumatic growth, and positive affect are highlighted. The trauma field would benefit from accumulation of evidence for promising CIH interventions, evaluation of potential mechanisms, and examination of health and wellbeing outcomes. With the paucity of high-quality trials, it would be premature to recommend CIH interventions as first-line treatments. However, the emerging literature on CIH continues to advance our understanding of what works and how these interventions exert their effects.

Complementary and Integrative Health (CIH) interventions for trauma that target holistic wellness above and beyond symptom reduction are increasingly used in the real world, though the evidence base lags.Papers in this issue support the emerging evidence for efficacy of mindfulness or other meditative or relaxation-based interventions.This special issue illustrates creative approaches but also the need for continued research establishing efficacy, evaluating more inclusive outcomes (e.g. a sense of wellbeing or ability to pursue valued life goals), and identifying potential mechanisms.

A Double-Blind Randomized Controlled Trial of Doxazosin for Co-Occurring PTSD and Alcohol Use Disorder in Veterans.

Objective: The aim of this study was to determine the efficacy of doxazosin, an α1-adrenergic antagonist, for the treatment of co-occurring posttraumatic stress disorder (PTSD) and alcohol use disorder (AUD).Methods: This 12-week, double-blind, randomized controlled trial of doxazosin (16 mg/d) was conducted between June 2016 and December 2019 at the Ralph H. Johnson VA Medical Center in Charleston, South Carolina. Participants were military veterans (N = 141) who met DSM-5 criteria for current PTSD and AUD and were randomly assigned to receive doxazosin (n = 70) or placebo (n = 71). Primary outcome measures were the Clinician Administered PTSD Scale (CAPS-5), the PTSD Checklist for DSM-5 (PCL-5), and the Timeline Follow-Back (TLFB).Results: Findings from the intent-to-treat analyses revealed that participants in both groups demonstrated statistically significant reductions in CAPS-5 and PCL-5 scores (P < .0001), but, contrary to hypotheses, no significant differences were observed between groups. Percent drinking days and percent heavy drinking days also decreased significantly during treatment, but there were no differences between groups (P < .0001). Abstinence during treatment was significantly higher in the doxazosin versus the placebo group (22% vs 7%, P = .017); however, participants in the doxazosin group consumed a greater number of drinks on drinking days (6.15 vs 4.56, P = .0096). A total of 74.5% of the sample completed the treatment phase, and there were no group differences in retention or adverse events.Conclusions: Doxazosin was safe and tolerable but was not more effective than placebo in reducing PTSD or AUD severity in this dually diagnosed sample. Clinical considerations such as heterogeneity of PTSD and AUD presentation and potential moderators are discussed in the context of future research directions.Trial Registration: ClinicalTrials.gov Identifier: NCT02500602.

Massed vs Intensive Outpatient Prolonged Exposure for Combat-Related Posttraumatic Stress Disorder: A Randomized Clinical Trial.

Importance: Improved, efficient, and acceptable treatments are needed for combat-related posttraumatic stress disorder (PTSD). Objective: To determine the efficacy of 2 compressed prolonged exposure (PE) therapy outpatient treatments for combat-related PTSD. Design, Setting, and Participants: This randomized clinical trial was conducted among military personnel and veterans at 4 sites in Texas from 2017 to 2019. Assessors were blinded to conditions. Data were analyzed from November 2020 to October 2022. Interventions: The interventions were massed-PE, which included 15 therapy sessions of 90 minutes each over 3 weeks, vs intensive outpatient program PE (IOP-PE), which included 15 full-day therapy sessions over 3 weeks with 8 treatment augmentations. The IOP-PE intervention was hypothesized to be superior to massed-PE. Main Outcomes and Measures: Coprimary outcomes included the Clinician-Administered PTSD Scale for Diagnostic and Statistical Manual of Mental Disorders (Fifth Edition) (DSM-5) (CAPS-5) and the PTSD Checklist for DSM-5 (PCL-5) administered at baseline and posttreatment follow-ups. Measures ranged from 0 to 80, with higher scores indicating greater severity. Diagnostic remission and reliable change were secondary outcomes. Results: Among 319 military personnel and veterans screened, 234 were randomized (mean [SD] age, 39.20 [7.72] years; 182 [78%] male participants), with 117 participants randomized to IOP-PE and 117 participants randomized to massed-PE. A total of 61 participants (26%) were African American, 58 participants (25%) were Hispanic, and 102 participants (44%) were White; 151 participants (65%) were married. Linear mixed-effects models found that CAPS-5 scores decreased in both treatment groups at the 1-month follow-up (IOP-PE: mean difference, -13.85 [95% CI, -16.47 to -11.23]; P < .001; massed-PE: mean difference, -14.13 [95% CI, -16.63 to -11.62]; P < .001). CAPS-5 change scores differed from 1- to 6-month follow-ups (mean difference, 4.44 [95% CI, 0.89 to 8.01]; P = .02). PTSD symptoms increased in massed-PE participants during follow-up (mean difference, 3.21 [95% CI, 0.65 to 5.77]; P = .01), whereas IOP-PE participants maintained treatment gains (mean difference, 1.23 [95% CI, -3.72 to 1.27]; P = .33). PCL-5 scores decreased in both groups from baseline to 1-month follow-up (IOP-PE: mean difference, -21.81 [95% CI, -25.57 to -18.04]; P < .001; massed-PE: mean difference, -19.96 [95% CI, -23.56 to -16.35]; P < .001) and were maintained at 6 months (IOP-PE: mean change, -0.21 [95% CI, -3.47 to 3.06]; P = .90; massed-PE: mean change, 3.02 [95% CI, -0.36 to 6.40]; P = .08). Both groups had notable PTSD diagnostic remission at posttreatment (IOP-PE: 48% [95% CI, 36% to 61%] of participants; massed-PE: 62% [95% CI, 51% to 73%] of participants), which was maintained at 6 months (IOP-PE: 53% [95% CI, 40% to 66%] of participants; massed-PE: 52% [95% CI, 38% to 66%] of participants). Most participants demonstrated reliable change on the CAPS-5 (61% [95% CI, 52% to 69%] of participants) and the PCL-5 (74% [95% CI, 66% to 81%] of participants) at the 1-month follow-up. Conclusions and Relevance: These findings suggest that PE can be adapted into compressed treatment formats that effectively reduce PTSD symptoms. Trial Registration: ClinicalTrials.gov Identifier: NCT03529435.

Study protocol for a revised randomized trial: Remotely delivered Tai Chi and wellness for Gulf War illness.

BACKGROUND: Many of the 700,000 American military personnel deployed to the Persian Gulf region in 1990 and 1991 have since reported health symptoms of unknown etiology. This cluster of symptoms has been labeled Gulf War Illness and include chronic musculoskeletal pain, fatigue, headaches, memory and attention difficulties, gastrointestinal complaints, skin abnormalities, breathing problems, and mood and sleep problems [1,2]. There have been few high-quality intervention trials and no strong evidence to support available treatments [3]. Tai Chi is an ancient Chinese martial art with benefits that include enhancing physical and mental health and improving quality of life for those with chronic conditions. PROPOSED METHODS: In this randomized controlled trial, GW Veterans are randomly assigned to either Tai Chi or a Wellness control condition, with both remotely delivered intervention groups meeting twice a week for 12 weeks. The primary aim is to examine if Tai Chi is associated with greater improvements in GWI symptoms in Veterans with GWI compared to a Wellness intervention. Participants will receive assessments at baseline, 12 weeks (post-intervention), and follow-up assessments 3- and 9-months post-intervention. The primary outcome measure is the Brief Pain Inventory that examines pain intensity and pain interference. CONCLUSION: This trial will produce valuable results that can have a meaningful impact on healthcare practices for GWI. If proven as a helpful treatment for individuals with GWI, it would support the implementation of remotely delivered Tai Chi classes that Veterans can access from their own homes.

A pilot randomized effectiveness trial of the unified protocol in trauma-exposed veterans.

BACKGROUND: The unified protocol (UP) is a promising transdisgnostic treatment for emotional disorders; limited data exists with trauma-exposed populations. This study compared effectiveness of the UP, presented centered therapy (PCT), and treatment as usual (TAU) in trauma-exposed veterans presenting to routine care. METHOD: Trauma-exposed veterans with one or more emotional disorder diagnoses participated in a pilot hybrid-1 effectiveness/preimplementation study. Thirty-seven male and female veterans were randomized to one of three conditions. RESULTS: Multilevel growth curve modeling demonstrated improvement over time across conditions with large effect sizes (range: -2.15 to -3.32), with the UP demonstrating the greatest change. The between group effect sizes for reductions in number of comorbid diagnoses were medium to small and statistically significant (TAU and UP, d = 0.49, p = .056; TAU and PCT d = 0.18, p = .166, UP and PCT d = 0.31, p = .229). Only the UP led to a decrease in the number of comorbid diagnoses (d = -0.71). Psychosocial functioning varied by group, with slight increases in impairment in PCT and TAU, and medium effect size reduction in the UP. Only the UP exhibited significant decreases in self-reported anxiety and depression. Between group differences for UP and PCT were medium to large and statistically significant for depression across two measures (d = -0.72 to d = -1.40). CONCLUSIONS: This represents the first trial examining effectiveness of the UP, PCT, and TAU in trauma-exposed veterans. Despite a small sample, large effect size differences demonstrated promising advantages for the UP. Trial Registration Number: NCT02944994.

Randomised controlled trial evaluating the effects of screening and referral for social determinants of health on Veterans' outcomes: protocol.

INTRODUCTION: Health policy leaders recommend screening and referral (S&R) for unmet social needs (eg, food) in clinical settings, and the American Heart Association recently concluded that the most significant opportunities for reducing cardiovascular disease (CVD) death and disability lie with addressing the social determinants of CVD outcomes. A limited but promising evidence base supports these recommendations, but more rigorous research is needed to guide health care-based S&R efforts. Funded by the Veteran Health Administration (VA), the study described in this paper will assess the efficacy of S&R on Veterans' connections to new resources to address social needs, reduction of unmet needs and health-related outcomes (adherence, utilisation and clinical outcomes). METHODS AND ANALYSIS: We will conduct a 1-year mixed-methods randomised controlled trial at three VA sites, enrolling Veterans with CVD and CVD-risk. 880 Veterans experiencing one or more social needs will be randomised within each site (n=293 per site) to one of three study arms representing referral mechanisms of varying intensity (screening only, screening and provision of resource sheet(s), screening and provision of resource sheet(s) plus social work assistance). For each Veteran, we will examine associations of unmet social needs with health-related outcomes at baseline, and longitudinally compare the impact of each approach on connection to new resources (primary outcome) and follow-up outcomes over a 12-month period. We will additionally conduct qualitative interviews with key stakeholders, including Veterans to identify potential explanatory factors related to the relative success of the interventions. ETHICS AND DISSEMINATION: Ethics approval was obtained from the VA Central Internal Review Board on 13 July 2021 (reference #: 20-07-Amendment No. 02). Findings will be disseminated through reports, lay summaries, policy briefs, academic publications, and conference presentations. TRIAL REGISTRATION NUMBER: NCT04977583.

Tai Chi and Qigong for trauma exposed populations: A systematic review.

Background: Trauma exposure and posttraumatic stress are highly prevalent and comorbid with health problems. Despite the apparent systemic nature of post-traumatic stress, recommended treatments neglect trauma's deleterious effects on health. Integrative mind-body treatments for posttraumatic stress, such as Tai Chi and Qigong (TCQ), may offer a promising adjunct to first-line treatments. Method: A systematic search was conducted to identify trials that examined Tai Chi and/or Qigong as treatments for trauma-exposed populations. Studies were examined for rigor; design, sample and intervention characteristics, dropout, attendance, satisfaction, acceptability, and key findings were systematically extracted. Results: The 6 studies included are all pilot or feasibility trials with descriptive or mixed-methods outcomes. No randomized trials or rigorous studies were identified. Dropout rates ranged widely, and adverse reactions were not evident. Reported satisfaction was high and benefits of relaxation, reductions in mental health symptoms, and improvements in pain and physical and cognitive functioning were noted. Limitations: All the studies were non-rigorous and relatively small, with no comparison groups, or follow-up assessments; in many cases, posttraumatic stress symptoms were not formally assessed. Conclusions: The paucity and lack of rigor of the studies identified for this review highlights the need for larger, methodologically sound clinical trials. The reviewed studies suggest that TCQ practices have the potential to reduce symptoms and improve functioning for individuals exposed to trauma and provide evidence that TCQ is feasible, acceptable, and low risk in these populations. Possible mechanistic pathways supporting TCQ as a treatment for posttraumatic stress are considered.

STRONG STAR and the Consortium to Alleviate PTSD: Shaping the future of combat PTSD and related conditions in military and veteran populations.

The STRONG STAR Consortium (South Texas Research Organizational Network Guiding Studies on Trauma and Resilience) and the Consortium to Alleviate PTSD are interdisciplinary and multi-institutional research consortia focused on the detection, diagnosis, prevention, and treatment of combat-related posttraumatic stress disorder (PTSD) and comorbid conditions in military personnel and veterans. This manuscript outlines the consortia's state-of-the-science collaborative research model and how this can be used as a roadmap for future trauma-related research. STRONG STAR was initially funded for 5 years in 2008 by the U.S. Department of Defense's (DoD) Psychological Health and Traumatic Brain Injury Research Program. Since the initial funding of STRONG STAR, almost 50 additional peer-reviewed STRONG STAR-affiliated projects have been funded through the DoD, the U.S. Department of Veterans Affairs (VA), the National Institutes of Health, and private organizations. In 2013, STRONG STAR investigators partnered with the VA's National Center for PTSD and were selected for joint DoD/VA funding to establish the Consortium to Alleviate PTSD. STRONG STAR and the Consortium to Alleviate PTSD have assembled a critical mass of investigators and institutions with the synergy required to make major scientific and public health advances in the prevention and treatment of combat PTSD and related conditions. This manuscript provides an overview of the establishment of these two research consortia, including their history, vision, mission, goals, and accomplishments. Comprehensive tables provide descriptions of over 70 projects supported by the consortia. Examples are provided of collaborations among over 50 worldwide academic research institutions and over 150 investigators.

Manage Emotions to Reduce Aggression: A Pilot Study of a Brief Treatment to Help Veterans Reduce Impulsive Aggression.

Veterans with posttraumatic stress disorder (PTSD) report more aggression than civilians with PTSD. Because emotion regulation difficulties mediated the relationship between PTSD symptoms and impulsive aggression in veterans, we developed an intervention to increase emotion regulation skills. This pilot study tested the feasibility and acceptability of a three-session treatment, Manage Emotions to Reduce Aggression (MERA), and examined its effectiveness at reducing aggression and emotion dysregulation. Male combat veterans with PTSD and impulsive aggression completed assessments before and 4 weeks after MERA. Overt Aggression Scale measured frequency of aggression; Difficulties in Emotion Regulation Scale assessed emotion dysregulation. Most veterans (95%) who completed MERA and the posttreatment assessment (n = 20) reported MERA was helpful. Veterans in the intent-to-treat sample demonstrated a significant decrease in their frequency of aggression (Cohen's d = -0.55) and emotion dysregulation (Cohen's d = -0.55). MERA may be an innovative treatment that helps veterans reduce aggression.

Intensive, Multi-Couple Group Therapy for PTSD: A Nonrandomized Pilot Study With Military and Veteran Dyads.

Cognitive-behavioral conjoint therapy for posttraumatic stress disorder (CBCT for PTSD; Monson & Fredman, 2012) is efficacious in improving PTSD symptoms and relationship adjustment among couples with PTSD. However, there is a need for more efficient delivery formats to maximize engagement and retention and to achieve faster outcomes in multiple domains. This nonrandomized trial was designed to pilot an abbreviated, intensive, multi-couple group version of CBCT for PTSD (AIM-CBCT for PTSD) delivered over a single weekend for 24 couples that included an active-duty service member or veteran with PTSD who had deployed in support of combat operations following September 11, 2001. All couples completed treatment. Assessments conducted by clinical evaluators 1 and 3 months after the intervention revealed significant reductions in clinician-rated PTSD symptoms (ds = -0.77 and -0.98, respectively) and in patients' self-reported symptoms of PTSD (ds = -0.73 and -1.17, respectively), depression (ds = -0.60 and -0.75, respectively), anxiety (ds = -0.63 and -0.73, respectively), and anger (ds = -0.45 and -0.60, respectively), relative to baseline. By 3-month follow-up, partners reported significant reductions in patients' PTSD symptoms (d = -0.56), as well as significant improvements in their own depressive symptoms (d = -0.47), anxiety (d = -0.60), and relationship satisfaction (d = 0.53), relative to baseline. Delivering CBCT for PTSD through an abbreviated, intensive multi-couple group format may be an efficient strategy for improving patient, partner, and relational well-being in military and veteran couples with PTSD.

Acceptability of a Wellness Group Program for Veterans With Symptoms of Posttraumatic Stress Disorder.

BACKGROUND: Although there are effective evidence-based treatments for posttraumatic stress disorder (PTSD), many individuals drop out or do not benefit from treatment. There is a need for new treatments, including approaches that are nontrauma focused. OBJECTIVE: The purpose of this program evaluation was to investigate the acceptability of a Wellness Group designed to promote healthy behaviors and adaptive coping when offered to veterans with PTSD. METHODS: Nine veterans in a PTSD outpatient clinic enrolled in a 12-week, 24-session Wellness Group. Acceptability of the intervention was evaluated with attendance data, questionnaires, and interviews. RESULTS: Group attendance rates were high and no participants dropped out of treatment. Treatment satisfaction was high and all veterans reported gains in at least 3 of the 8 Wellness domains covered. Interview data supported the findings that veterans had positive reactions to the group. CONCLUSION: A Wellness approach may offer a low-cost alternative or supplementary treatment for veterans with PTSD that is highly acceptable and may improve health behaviors, quality of life, and coping skills.

The Effects of Tai Chi Mind-Body Approach on the Mechanisms of Gulf War Illness: an Umbrella Review.

Gulf War illness (GWI) is a chronic and multisymptom disorder affecting military veterans deployed to the 1991 Persian Gulf War. It is characterized by a range of acute and chronic symptoms, including but not limited to, fatigue, sleep disturbances, psychological problems, cognitive deficits, widespread pain, and respiratory and gastrointestinal difficulties. The prevalence of many of these chronic symptoms affecting Gulf War veterans occur at markedly elevated rates compared to nondeployed contemporary veterans. To date, no effective treatments for GWI have been identified. The overarching goal of this umbrella review was to critically evaluate the evidence for the potential of Tai Chi mind-body exercise to benefit and alleviate GWI symptomology. Based on the most prevalent GWI chronic symptoms and case definitions established by the Centers for Disease Control and Prevention and the Kansas Gulf War Veterans Health Initiative Program, we reviewed and summarized the evidence from 7 published systematic reviews and meta-analyses. Our findings suggest that Tai Chi may have the potential for distinct therapeutic benefits on the major prevalent symptoms of GWI. Future clinical trials are warranted to examine the feasibility, efficacy, durability and potential mechanisms of Tai Chi for improving health outcomes and relieving symptomology in GWI.

Alliance across group treatment for veterans with posttraumatic stress disorder: The role of interpersonal trauma and treatment type.

OBJECTIVE: Examine initial levels and pattern of change of alliance in group treatment for posttraumatic stress disorder (PTSD) for veterans. METHOD: One hundred and seventy-eight male veterans with PTSD were recruited for this study. Participants were randomly assigned to either group cognitive behavioral therapy (GCBT) or to group present-centered therapy (GPCT). Alliance with fellow group members was assessed every other session throughout the group (total of seven assessments). Hierarchical linear modeling was used to determine whether treatment condition or index trauma type (interpersonal or non-interpersonal) impacted initial levels of alliance or change in alliance over time. RESULTS: Alliance increased significantly throughout treatment in both conditions. The presence of an interpersonal index event, compared to a non-interpersonal index event, did not significantly impact either initial levels of alliance or change in alliance over time. Participants in the GCBT condition experienced significantly greater growth in alliance over time compared to those in the GPCT condition (p > .05), but did not have significantly different initial alliance ratings. CONCLUSIONS: The components and focus of the GCBT treatment may have facilitated more rapid bonding among members. Interpersonal traumatic experience did not negatively impact group alliance.

A systematic review of randomized trials of mind-body interventions for PTSD.

OBJECTIVE: To systematically review outcomes from randomized controlled trials (RCTs) of mind-body treatments for PTSD. METHODS: Inclusion criteria based on guidelines for assessing risk of bias were used to evaluate articles identified through electronic literature searches. RESULTS: Twenty-two RCTs met inclusion standards. In most of the nine mindfulness and six yoga studies, significant between-group effects were found indicating moderate to large effect size advantages for these treatments. In all seven relaxation RCT's, relaxation was used as a control condition and five studies reported significant between-group differences on relevant PTSD outcomes in favor of the target treatments. However, there were large within-group symptom improvements in the relaxation condition for the majority of studies. CONCLUSIONS: Although many studies are limited by methodologic weaknesses, recent studies have increased rigor and, in aggregate, the results for mindfulness, yoga, and relaxation are promising. Recommendations for design of future mind-body trials are offered.

Explication and Definition of Mental Health Recovery: A Systematic Review.

This review assessed the concordance of the literature on recovery with the definition and components of recovery developed by the Substance Abuse and Mental Health Services Administration (SAMHSA). Each SAMHSA identified recovery component was first explicated with synonyms and keywords and made mutually exclusive by authors. Inter-rater reliability was established on the coding of the presence of 17 recovery components and dimensions in 67 literature reviews on the recovery concept in mental health. The review indicated that concordance varied across SAMHSA components. The components of recovery with greatest concordance were: individualized/person centered, empowerment, purpose, and hope.

Initiation, dropout, and outcome from evidence-based psychotherapies in a VA PTSD outpatient clinic.

Trauma-focused, evidence-based psychotherapies (TF-EBPs) for posttraumatic stress disorder (PTSD) have been widely promoted in the Veterans Health Administration to provide access to state-of-the-art treatments, but dropout rates may affect the impact of TF-EBPs. The current study summarizes findings from a program evaluation of 67 veterans assigned to trauma-focused treatment in a Veterans Affairs outpatient PTSD clinic. Outcomes of interest include attendance rates, dropout rates and patterns, treatment paths, changes in self-reported symptoms, and clinician ratings. Nine veterans (13.4%) did not attend a first session and 15 (22.4%) dropped out before session 4. Twenty-three (33.8%) received either a modified version of the TF-EBP or switched to a different treatment. Only 11 (16.4%) completed the assigned TF-EBP, but 10 of those 11 (90.9%) were rated by their therapist as improved. These results align with previous research documenting high dropout rates from PTSD treatment in veterans and substantial improvements for those who complete TF-EBPs. Future study of methods to enhance retention in TF-EBP treatments is needed. (PsycINFO Database Record (c) 2018 APA, all rights reserved).

Feasibility, qualitative findings and satisfaction of a brief Tai Chi mind-body programme for veterans with post-traumatic stress symptoms.

OBJECTIVE: To examine feasibility, qualitative feedback and satisfaction associated with a 4-session introduction to Tai Chi for veterans with post-traumatic stress symptoms. DESIGN: We observed and reported recruitment and retention rates, participant characteristics, adherence, and satisfaction across 2 cohorts. We also examined qualitative feedback provided by questionnaires, focus groups and individual interviews. MAIN OUTCOME MEASURES: Rates of recruitment and retention, focus group and individual feedback interviews, self-reported satisfaction. PARTICIPANTS: 17 veterans with post-traumatic stress symptoms. RESULTS: Almost 90% (17/19) of those eligible following the telephone screen enrolled in the programme. Three-quarters (76.4%) of the participants attended at least 3 of the 4 Tai Chi sessions. Qualitative data analysis revealed themes indicating favourable impressions of the Tai Chi sessions. In addition, participants reported feeling very engaged during the sessions, and found Tai Chi to be helpful for managing distressing symptoms (ie, intrusive thoughts, concentration difficulties, physiological arousal). Participants also reported high satisfaction: 93.8% endorsed being very or mostly satisfied with the programme. All participants (100%) indicated that they would like to participate in future Tai Chi programmes and would recommend it to a friend. CONCLUSIONS: Tai Chi appears to be feasible and safe for veterans with symptoms of post-traumatic stress disorder (PTSD), is perceived to be beneficial and is associated with high rates of satisfaction. This study highlights the need for future investigation of Tai Chi as a novel intervention to address symptoms of PTSD.

Temporal Associations Among Chronic PTSD Symptoms in U.S. Combat Veterans.

The present study examined fluctuation over time in symptoms of posttraumatic stress disorder (PTSD) among 34 combat veterans (28 with diagnosed PTSD, 6 with subclinical symptoms) assessed every 2 weeks for up to 2 years (range of assessments = 13-52). Temporal relationships were examined among four PTSD symptom clusters (reexperiencing, avoidance, emotional numbing, and hyperarousal) with particular attention to the influence of hyperarousal. Multilevel cross-lagged random coefficients autoregression for intensive time series data analyses were used to model symptom fluctuation decades after combat experiences. As anticipated, hyperarousal predicted subsequent fluctuations in the 3 other PTSD symptom clusters (reexperiencing, avoidance, emotional numbing) at subsequent 2-week intervals (rs = .45, .36, and .40, respectively). Additionally, emotional numbing influenced later reexperiencing and avoidance, and reexperiencing influenced later hyperarousal (rs = .44, .40, and .34, respectively). These findings underscore the important influence of hyperarousal. Furthermore, results indicate a bidirectional relationship between hyperarousal and reexperiencing as well as a possible chaining of symptoms (hyperarousal → emotional numbing → reexperiencing → hyperarousal) and establish potential internal, intrapersonal mechanisms for the maintenance of persistent PTSD symptoms. Results suggested that clinical interventions targeting hyperarousal and emotional numbing symptoms may hold promise for PTSD of long duration.

Targeted recruitment of adults with type 2 diabetes for a physical activity intervention.

Recruiting sufficient numbers of participants for physical activity trials for individuals with diabetes can be difficult because there are often many behavioral demands for participants, and inclusion and exclusion criteria can be extensive. This study examined the recruitment strategies used for a randomized, controlled trial designed to investigate the efficacy of an automated telephone intervention to promote physical activity in adults with type 2 diabetes in an urban Veterans Administration health care system. Traditional recruitment approaches of posting flyers and obtaining referrals from clinicians did not yield sufficient numbers of interested patients. Using the electronic medical record system to identify patients with uncontrolled diabetes allowed staff to send targeted mailings to participants, and 77% of participants were recruited using this method. The targeted mailing approach elicited a positive response rate of 12% (328 of 2,764 potential participants identified) and appeared to produce a more representative and appropriate sample than other recruitment methods used. Lessons learned in this study may be helpful to researchers in future trials who attempt to recruit participants with diabetes for physical activity protocols.

Examining mechanisms of change in a yoga intervention for women: the influence of mindfulness, psychological flexibility, and emotion regulation on PTSD symptoms.

OBJECTIVE: This study explored possible mechanisms through which symptoms of posttraumatic stress disorder (PTSD) were reduced in a randomized controlled trial comparing the effect of a yoga intervention with an assessment control. METHOD: We examined whether changes in psychological flexibility, mindfulness, and emotion regulation strategies (expressive suppression and reappraisal) were associated with posttreatment PTSD symptoms for 38 women with Diagnostic and Statistical Manual of Mental Disorders Fourth Edition full or subthreshold PTSD. RESULTS: Hierarchical linear regression models revealed that expressive suppression significantly decreased for the yoga group relative to the assessment control. Psychological flexibility increased significantly for the control but not yoga group. However, increases in psychological flexibility were associated with decreases in PTSD symptoms for the yoga but not control group. CONCLUSION: Preliminary findings suggest that yoga may reduce expressive suppression and may improve PTSD symptoms by increasing psychological flexibility. More research is needed to replicate and extend these findings.